$6,800 individual / $13,600 family. Does not apply to preventive care. What is the overall deductible?

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Questions:  Call 877-687-1196, Relay Texas/TTY 800-735-2989 or visit us at http://ambetter.superiorhealthplan.com/.

Ambetter Essential Care 1 (2016) + Vision

Coverage Period:01/01/2016 - 12/31/2016

Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan Type: EPO

This is only a summary.

 If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan

document at http://ambetter.superiorhealthplan.com/ or by calling 877-687-1196, Relay Texas/TTY 800-735-2989

Important Questions Answers Why this Matters:

What is the overall deductible?

$6,800 individual / $13,600 family. Does not apply to preventive care.

You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy plan or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible.

Are there other

deductibles for specific

services? No

You don’t have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers.

Is there an out-of-pocket-limit on my expenses?

Yes, for network providers $6,800 individual/$13,600 family. No, for non-network providers.

The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. What is not included in

the out–of–pocket limit?

Premiums, balance-billed charges, and non-network services this

plan doesn't cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Is there an overall annual

limit on what the plan

pays? No

The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits.

Does this plan use a network of providers?

Yes. See Find a Provider or call 1-877-687-1196 for  a list of participating providers.

If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers.

Do I need a referral to

see a specialist? No, you don't need a referral tosee a specialist. You can see the authorization is required from this plan.specialist you choose without permission from this plan; however, prior Are there services this

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• Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service

• Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven’t met your deductible.

• The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing).

• This plan may encourage you to use in-network providers by charging you lower deductibles, copayments, and coinsurance amounts.

Common Medical

Event Services You May Need

Your Cost If You Use an In-network Provider

Your Cost If You Use an

Out-of-network ProviderLimitations & Exceptions

If you visit a health care provider's office or clinic

Primary care visit to treat an injury or illness No charge afterdeductible Not covered

---None---Specialist visit No charge afterdeductible Not covered Prior approval required. Other practitioner office visit No charge afterdeductible Not covered

---None---Preventive care/screening/immunization No Charge Not covered

---None---If you have a test Diagnostic test (x-ray, blood work)

No charge after

deductible Not covered Prior approval required. Imaging (CT/PET scans, MRIs) No charge afterdeductible Not covered Prior approval required.

If you need drugs to treat your illness or condition

More information about

Generic drugs $20 Copay Not covered

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Common Medical

Event Services You May Need

Your Cost If You Use an In-network Provider

Your Cost If You Use an

Out-of-network ProviderLimitations & Exceptions

If you have outpatient surgery

Facility fee (e.g., ambulatory surgery center) No charge afterdeductible Not covered Prior approval required. Physician/surgeon fees No charge afterdeductible Not covered Prior approval required.

If you need immediate medical attention

Emergency room services No charge afterdeductible /visit No charge afterdeductible /visit ---None---Emergency medical transportation No charge afterdeductible No charge afterdeductible ---None---Urgent care No charge afterdeductible Not covered

---None---If you have a hospital stay

Facility fee (e.g., hospital room) No charge afterdeductible Not covered Prior approval required. Physician/surgeon fee No charge afterdeductible Not covered Prior approval required.

If you have mental health, behavioral health, or substance abuse needs

Mental/Behavioral health outpatient services No charge afterdeductible Not covered Prior approval required. Mental/Behavioral health inpatient services No charge afterdeductible Not covered Prior approval required. Substance use disorder outpatient services No charge afterdeductible Not covered Prior approval required. Substance use disorder inpatient services No charge afterdeductible Not covered Prior approval required.

If you are pregnant Prenatal and postnatal care

No charge after

deductible Not covered Prior approval required. Delivery and all inpatient services No charge afterdeductible Not covered Prior approval required.

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Common Medical

Event Services You May Need

Your Cost If You Use an In-network Provider

Your Cost If You Use an

Out-of-network ProviderLimitations & Exceptions

If you need help recovering or have other special health needs

Home health care No charge afterdeductible Not covered Prior approval required. 60 Visit(s) perYear Rehabilitation services No charge afterdeductible Not covered Prior approval required. 35 Visit(s) peryear. Habilitation services No charge afterdeductible Not covered Prior approval required. 35 Visit(s) perbenefit per year. Skilled nursing care No charge afterdeductible Not covered Prior approval required. 25 Days per yearin a facility. Durable medical equipment No charge afterdeductible Not covered Prior approval required.

Hospice service No charge afterdeductible Not covered Prior approval required If your child needs

dental or eye care

Eye exam $0 Copay/visit Not covered 1 Visit(s) per Year

Glasses $0 Copay/pair Not covered 1 Item(s) per Year

Dental check-up Not covered Not covered

---None---Excluded Services & Other Covered Services

Services Your Plan Does Not Cover (This isn't a complete list. Check your policy or plan document for other excluded services.) • Acupuncture

• Infertility treatment (Coverage for the diagnosis of infertility only)

• Private-duty nursing

• Bariatric surgery • Long-term care • Weight loss programs

• Dental Care (Adult)

• Non-emergency care when traveling outside the U.S.

Other Covered Services (This isn't a complete list. Check your policy or plan document for other covered services and your costs for these services.)

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Your Rights to Continue Coverage

Federal and State laws may provide protections that allow you to keep this health insurance coverage as long as you pay your premium. There are exceptions, however, such as if:

• You commit fraud

• The insurer stops offering services in the State • You move outside the coverage area

For more information on your rights to continue coverage, contact the insurer at 877-687-1196, Relay Texas/TTY 800-735-2989. You may also contact your state insurance department at Texas Department of Insurance, 333 Guadalupe, Austin, TX 78701, Phone No. (800) 578-4677.

Your Grievance and Appeals Rights:

If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact: Texas Department of Insurance, 333 Guadalupe, Austin, TX 78701, Phone No. (800) 578-4677.

Does this Coverage Provide Minimum Essential Coverage?

The Affordable Care Act requires most people to have health care coverage that qualifies as "minimum essential coverage." This plan or policy does provide minimum essential coverage.

Does this Coverage Meet the Minimum Value Standard?

The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides.

Language Access Services:

Spanish (Español): Para obtener asistencia en Español, llame al 877-687-1196, Relay Texas/TTY 800-735-2989

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About these Coverage

Examples:

These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans.

This is not a cost

estimator.

Don't use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different.  

See the next page for important information about these examples.

Having a baby

(normal delivery)

Amount owed to providers: $7,540Plan pays $2,120

Patient pays $5,420 Sample care costs:

Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900

Anesthesia $900

Laboratory tests $500

Prescriptions $200

Radiology $200

Vaccines, other preventive $40

Total $7,540 Patient pays Deductibles $5,200 Copays $20 Coinsurance $0 Limits or exclusions $200 Total $5,420

Managing type 2 diabetes

(routine maintenance of a well-controlled condition)

Amount owed to providers: $5,400Plan pays $2,120

Patient pays $3,280 Sample care costs:

Prescriptions $2,900

Medical Equipment and Supplies $1,300 Office Visits and Procedures $700

Education $300

Laboratory tests $100

Vaccines, other preventive $100

Total $5,400 Patient pays Deductibles $2,400 Copays $800 Coinsurance $0 Limits or exclusions $80 Total $3,280

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Questions: Call 877-687-1196, Relay Texas/TTY 800-735-2989 or visit us at http://ambetter.superiorhealthplan.com/.

Questions and answers about the Coverage Examples:

What are some of the

assumptions behind the

Coverage Examples?

• Costs don’t include premiums.

• Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren’t specific to a particular geographic area or health plan.

• The patient’s condition was not an excluded or preexisting condition.

• All services and treatments started and ended in the same coverage period.

• There are no other medical expenses for any member covered under this plan.

• Out-of-pocket expenses are based only on treating the condition in the example.

• The patient received all care from in-network providers. If the patient had received care from out-of-network providers, costs would have been higher.

What does a Coverage Example

show?

For each treatment situation, the Coverage Examples helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn't covered or payment is limited.

Does the Coverage Example predict

my own care needs?

No. Treatments shown are just examples. The care you would receive for this condition could be different based on your doctor’s advice, your age, how serious your condition is, and many other factors.

Does the Coverage Example predict

my future expenses?

No. Coverage Examples are not cost estimators. You can’t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows.

Can I use Coverage Examples to

compare plans?

Yes. When you look at the Summary of Benefits and Coverage for other plans, you’ll find the same Coverage Examples. When you compare plans, check the “Patient Pays” box in each example. The smaller that number, the more coverage the plan provides.

Are there other costs I should

consider when comparing plans?

Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you’ll pay in out-of-pocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to

accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses.

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